What’s in the Water?What’s in the Air?

Michele C. Hlavsa, RN, MPHWater and Environment Activity Team

Division of Parasitic DiseasesCenters for Disease Control & Prevention

Swimming is fun and a great form of exercise, but… swimming can also lead to

illness and injuries

Recreational Water Illness (RWI)

Eye and respiratory irritation

Diarrheal illness

Diarrheal Illness is Common

High incidence of diarrhea in U.S.• ~ 8% of general public had diarrhea in

past month1

> 2% fecal incontinence (FI) in Wisconsin Family Health survey22

• 70% with FI <65 years old

1. Roy SL et al. 2006. J Water Health 4(Suppl 2):31–69.2. Nelson R et al. 1995. JAMA 274(7):559–61.

Fecal Contamination of Recreational Water is Common

Fellow bathers… shared water / communal bathing high bather loads heavy use by diapered and

toddler-aged children fecal accidents common• ~ 0.14g of feces on peri-anal surface/person

range: 0.01g (adults)–10g (children)1

1. Gerba CP. 2000. Quant Microbiol 2(1):55–68.

Exposure to Recreational Water

is High

Swimming is the 2nd most popular exercise activity in the United States ~ 350 million swimming visits each year1

Underestimate >7 years of age Swim >6 times in last year

1. US Bureau of the Census. 2005. Statistical Abstract of the United States. Arts, Recreation, & Travel: Recreation and Leisure Activities. www.census.gov/compendia/statab/cats/arts_recreation_travel/recreation_and_leisure_activities.html

Inadequate Pool Operation and Maintenance is NOT Uncommon

Pools / spa inspection data from 5 U.S. sites CA, FL, MN, PA, WY ~22,000 pool1 and ~5,000 spa2 inspections

8.3% (11%) of inspections resulted in immediate closure pending correction of violation

1. CDC. 2003. MMWR 52(22):513–6.2. CDC. 2004. MMWR 53(25):553–5.

Recreational Water–Associated Outbreaks of Gastroenteritis and Disinfected Venues

United States, 1997–2006*

Other includesCampylobacter, Salmonella.

Plesiomonas, mixed pathogens Chlorine resistant

Chlorine sensitive:Poor pool operation

& maintenance

Cryptosporidium68.3%

E. coli O157:H72.9%

Unknown 8.7%

Other 3.8% Giardia 2.96%

Shigella 6.7%Norovirus 6.7%

* N=104, Yoder JS et al. 2008. MMWR 57(SS-9):1-38.

Recreational Water–Associated Outbreaks of Cryptosporidiosis, by Water Treatment

United States, 1988–2007*

* N =128; Yoder JS et al. 2008. MMWR 57(SS-9):1-38.

0

5

10

15

20

25

30

88 91 94 97 2000 2003 2006Year

Num

ber

of O

utbr

eaks

Disinfected: Pool, water parks, interactive fountains

Untreated: Lakes, oceans, rivers

Recreational Water–Associated Outbreaks of Cryptosporidiosis — United States, 2007*

* N=26, based on preliminary 2007 reports (as of 09/16/08)

Crypto is in Our Community. Is it in Our Pools? Yes.

CountryCrypto

Positive% (n)

GiardiaPositive

% (n)

United States1 1.9% (3/160) 6.9% (11/160)

Netherlands2* 5.9% (9/153) 7.2% (9/153)

France3* 2.1% (1/48) 0.0% (0/48)

Italy4* 38.1% (8/21) 28.6% (6/21)

1. Shields JM et al. 2008. Emer Infect Dis 14(6):948–950.2. Schets FM et al. J Water Health 2(3):191–200.3. Fournier S et al. 2002. FEMS Immunol Med Microbiol 33(2002):209–13.4. Olivieri R et al. 2006. Ann Ig 18(5):367–74.

* Indicates serial samples for given pools.Yellow font in table indicates backwash samples.

Cryptosporidiosis Outbreaks Linked to Recreational Water, by country

Worldwide, 1988–20051,2

Country Number of Outbreaks

United States 80

United Kingdom 53

Australia 6

Canada 3

Spain, Japan, New Zealand, Sweden 6

1. Beach MJ. Waterborne: Recreational Water. Fayer, Xiao L, eds. Cryptosporidium and cryptosporidiosis. 2nd edition. Boca Raton, FL: CRC Press; 2008:329–62.

2. Yoder JS et al. 2008. MMWR 57(SS-9):1-38.

Community-wide Cryptosporidiosis Outbreak — Kansas, 2003

Context Swim team members and day camp attendees shared

pool, ill with diarrhea One swim team coach encouraged ill swimmers to

compete Investigation

Multiple swim teams affected 12–55% of swim team members

Multiple pools affected One third of patients reported swimming in month

after diarrhea began Outcome

>700 people ill, community-wide outbreak

Source: Fox LM et al. Epi-2: Epi-Aid #2003-66

Cryptosporidiosis OutbreakNew Mexico, 2008

Context Competitive swimmer practiced and competed

while ill with diarrhea State and city championships

Investigation (preliminary findings) About 50% of patients reported swimming while ill

with diarrhea Outcome

>80 people ill >20 additional team pools potentially contaminated

across stateSource: Selvage D, Espinoza JA, Powers C.

Diarrhea and Swimming: The Solution

Become an activist swimmer Awareness Action Advocacy

Awareness

Visit www.cdc.gov/healthyswimming See webpage on prevention

www.cdc.gov/healthyswimming/prevention_materials.htm

Learn about how you can help stop the spread of RWIs such as diarrheal illness Don’t swim will ill with diarrhea

Don’t swim for 2 weeks after diarrhea has resolved if diagnosed with cryptosporidiosis

Avoid swallowing pool water

Action

Check pool water yourself Chlorine: 1–3 parts per million free chlorine pH: 7.2–7.8

Ask the pool operator If chlorine and pH levels checked at least 2 times

per day More often when the pool is heavily used

For the latest inspection score If he/she has specialized training in pool

operation

Talk to team members about diarrhea

Advocacy

Encourage operators to take steps that known to kill Crypto Add in-line ultraviolet radiation or ozone Hyperchlorinate

Example: 20 ppm chlorine for 12.75 hours

Promote healthy pools Advocate through USA Swimming

Talk to other swim teams Collaborate with pool operators and public health

What’s In the Water/Air at Indoor Pools?Chloramines, etc.

Chloramines or Combined Chlorines: The Problem

Form in water when free chlorine combines with urine or sweat Cause causes eye irritation

Evaporate from water and enter air Produce strong smell Cause respiratory irritation, possibly asthma

Linked to poorly maintained indoor pools and poor ventilation

Swimming Competition — Event A

Context >1,000 athletes Competitors experienced breathing problems

and headaches and had red, watery eyes Investigation

All exhaust fans shut down on first day Outcome

Brandon Hansen: “If you go in the pool for 10 minutes, it kills you. Right now, I can’t breathe in deep because I know I’ll cough.” Missed best time in 200 meter backstroke by almost 2

seconds Exhaust fans repaired before second day

Swimming Competition — Event B

Context Back-to-back competitions

Approximately a total of 2,000 athletes in 11 days

Investigation Water quality good in racing pool Difficulty maintaining water quality in practice pool

Lifeguards stationed on deck and at windows under surface to safely monitor all swimmers

Outcome <10% of competitors reported symptoms

Awareness

Visit www.cdc.gov/healthyswimming See webpage on irritants

www.cdc.gov/healthyswimming/irritants.htm

Enforce good hygiene among swimmers Shower with soap thoroughly before entering the

water Promote regular bathroom breaks

Action

Check pool water yourself Total chlorine = free chlorine + combined

chlorine Most states allow 0.2–0.4 parts per million

combined chlorine

Ask the pool operator If chlorine and pH levels checked at least 2 times

per day More often when the pool is heavily used

Talk to team members about combined chlorines

Advocacy

Encourage operators to take steps known to decrease combined chlorine levels Increase/improve ventilation Add In-line ultraviolet radiation Super-chlorinate

Increase free chlorine level to 10 times combined chlorine level under well-ventilated conditions

Promote healthy pools Advocate through USA Swimming

Talk to other swim teams Collaborate with pool operators and public health

Posters

Brochures

Pool Staff Newsletters

Factsheets

Staff & Patron FAQs

Healthy Swimming 2002All documents can be downloaded at:

w w w . c d c . g o v / h e a l t h y s w i m m i n g

Required Disclaimer from the Department of Health and

Human Services (Please Interpret as You See Fit)

“The findings and conclusions in this presentation have not been formally disseminated by CDC and should not be construed to represent any agency determination or policy.“

Acknowledgements

DPD Michael Beach Jonathan Yoder

NCEH/EHSB Jeff Dimond Charles Otto

EPO/PMR/EIS Charlotte Wheeler

NSPF, Tom Lachocki, Tracynda Davis

ARCH Chemical Water Technology Kiefer and Associates Trojan Technologies Biolabs US Filter

Cryptosporidiosis Outbreak Minnesota, 19981

Context Report of diarrheal illness among

swimmers Investigation

26 cases among different types of swimmers

41% (16 of 26 interviewed) competitive swimmers ill Spent more time in pool than other swimmers

No lapses in pool operation identified1. Lim LS et al. 2004. J Environ Hlth 67(1):20.

Cryptosporidiosis in the Community Utah, 2007

Context Increased reporting of cases

Magnitude >1,900 laboratory–confirmed cases Multiple counties and cities Highest case rate among young children

Response Alerted public, pools, healthcare providers, etc.

locally Spread community-wide

Banned children <5 years of age from swimming in public pools

Banning <5 Year Olds from Public Pools

Control measure for only extreme situations Inability to evaluate efficacy Enforceability?

Notification of all pool operators Parents sometimes uncooperative Revenue lost by pool managers / operators Opposition from the public

Feasibility long term? Possible negative public health consequences

Indoor Air Quality, Chemical Exposure Nebraska, 2007

Context Child hospitalized in intensive care after swimming

in indoor pool at Hotel A on Christmas Day Magnitude

23 other persons ill with burning / watery eyes, sore throat, and cough

Findings Risk factors: entering pool area, swimming in pool 26 violations: 0.8 ppm free chlorine, 4.2 ppm

combined chlorine, pH 3.95 Ventilation fan turned offBuss et al. 2007. MMWR 56(36):929–32.

Chemical Mixing Accident, Chemical Exposure — New York, 1990

Context Recirculation pump shut down after power failure,

feed pumps continued running Undiluted chlorine and acid surged into shallow end

of pool and released gas

Magnitude 21 children taken to hospital for difficulty breathing

Findings Inspection: no violations County Pool Code revised

Electrical interlock between recirculation and chemical feed pumps

Alarm to indicate recirculation pump has shut off

CDC Parent Focus Groups: Summary

Don’t consider swimming in poolas communal bathing / shared water

No clue about potential for disease transmission “chlorine kills everything”, “pool water is sterile”

Willing to contemplate changing behavior

Want education to enable informed decision making

2004 USA National Consumer League Poll

14% believe pool water is sterile

40% believe they are “somewhat” or “very” likely to get ill from swimming in a pool

82% believe you should never swim when ill with diarrhea What are the other 18% thinking???

Hypotheses

Real increase in transmission Improved surveillance Alinia (nitazoxanide or NTZ)

New and only approved drug to treat Crypto approved for 1–11 years of age in 2002 >12 years of age in 2004

Changing healthcare requests for testing? Increased awareness about link between

cryptosporidiosis and pool exposures

Bottom Line: Outbreaks are more likely to be detected in the future